Home blood pressure monitoring for hypertension best combined with intensive support

People who monitor their own blood pressure at home are most likely to see a benefit if they combine it with individually tailored intensive support, according to a new systematic literature review and meta-analysis published this week in PLOS Medicine by Richard McManus of the University of Oxford, UK, and colleagues.

Home blood pressure monitoring is currently recommended for people with high blood pressure so health professionals can make necessary adjustments to treatment. Previous research has shown that self-monitoring reduces clinic blood pressure by a small but statistically significant amount, but how best to implement it and for which patients it might be most useful remain unclear.

In this new study, researchers searched the existing medical literature for randomized trials that included self-monitoring of blood pressure in people with high blood pressure. They then used individual patient data from 25 studies, with up to 10,487 patients in total, to evaluate the effect of self-monitoring on blood pressure levels.

Overall, self-monitoring was associated with a clinic measurement of systolic blood pressure that was reduced by 3.2 mmHg (95% confidence interval [CI] -4.9 to -1.6) compared to usual care at 12 months. The effect, however, was strongly influenced by the intensity of professional support. This ranged from no significant effect on blood pressure with self-monitoring alone (1.0 mmHg reduction; 95% CI -3.3 to 1.2) to a significant blood pressure reduction (6.1 mmHg reduction; 95% CI -9.0 to -3.2) when self-monitoring was combined with additional support such as with education, lifestyle counseling, or medication adjustment managed by the patient themselves.

Self-monitoring was associated with greater blood pressure reductions in people on fewer antihypertensive medications and with higher systolic blood pressure before self-monitoring (up to 170 mmHg).

Lead author Richard McManus said: "Home self-monitoring has little effect on blood pressure control unless it's combined with individually tailored support delivered by either a nurse, physician or pharmacist. This can lead to important decreases in blood pressure and improved control with potential to reduce the risk of developing associated life-threatening conditions."

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Funding:

This research was funded by the Institute for Health Research School for Primary Care Research (NIHR SPCR number 112) and via an NIHR Professorship for RM (NIHR-RP-02-12-015). JS holds a Medical Research Council (MRC) Strategic Skills Postdoctoral Fellowship (MR/K022032/1). FDRH is part funded as Director of the National Institute for Health Research (NIHR) School for Primary Care Research (SPCR), Theme Leader of the NIHR Oxford Biomedical Research Centre (BRC), and Director of the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Oxford. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests:

I have read the journal's policy and the authors of this manuscript have the following competing interests: RJM has received research funding in terms of blood pressure monitors from Omron and Lloyds Healthcare; has received expenses and an honorarium from the Japanese Society of Hypertension and American Society of Nephrology. WJV is now employed by Microlife but was not at the time that the data contributed were collected. FDRH has in the past received limited free or subsidised BP measuring devices from Microlife and Omron to support hypertension research where there was no input from the companies to the design, funding, delivery, analysis, or interpretation of that research. SO is a consultant of Biotechmed Ltd. (provider of blood pressure telemonitoring services). SK has received research funding in terms of blood pressure monitors from Omron. HBB has received grant funding to Duke University from Sanofi, Johnson and Johnson, Takeda, WestMeadVaco, and Improved patient Outcome; has received an honorarium from Walgreens, Genentech, Sanofi; and has received funds for consulting for Sanofi. JPS received an MRC Strategic Skills Postdoctoral Fellowship (2013-2016) and now receives funding from the NIHR Oxford Collaborations for Leadership in Applied Health Research and Care. AB owns stocks in Insight Telehealth Systems LLC. MG received a research grant from the Heart and Stroke Foundation of Ontario prior to this work to conduct a study on self-monitoring of blood pressure, data from which are included in this meta-analysis. JG has held unrestricted investigator initiated grants from Pfizer and Boehringer-Ingelheim (BI) for unrelated research; is a member of the Lung Foundation Australia's (LFA) COPD-X guidelines committee. Pfizer, BI, or LFA did not have any role in my decision to participate in the work submitted by Tucker et al. IK has received travel grants and honoraria for speaking or participation at meetings from Sanofi-Genzyme and Shire concerning Fabry disease; has participated in clinical studies concerning diabetic nephropathy and hyperlipidemia sponsored by Bayer, Boehringer-Ingelheim, Merck Sharp and Dome and Pfizer.

Nuffield Department of Primary Care, University of Oxford, Oxford, United Kingdom
Center for Health Services Research in Primary Care, Durham VAMC, Durham, North Carolina, United States of America
Cardiology, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, United States of America
School of Psychology, University of Central Lancashire, Preston, United Kingdom
Thomas Addison Diabetes Unit, St. George's NHS Trust, London, United Kingdom
Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
Family Medicine, Memorial University of Newfoundland, St. John's, Canada
Kaiser Permanente Washington Health Research Institute, Seattle, Washington, United States of America
Department of Health Services, University of Washington School of Public Health, Seattle, Washington, United States of America
Division of Medicine, Turku University Hospital and University of Turku, Turku, Finland
Centre for Primary Care and Public Health, Queen Mary University of London, London, United Kingdom
Primary Care Research Unit of Mallorca, Baleares Health Services-IbSalut, Mallorca, Spain
Colorado School of Public Health, University of Colorado, Denver, Colorado, United States of America
Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
HealthPartners Institute for Education and Research, Minneapolis, Minnesota, United States of America
Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
Icahn School of Medicine at Mount Sinai New York, New York, New York, United States of America
Clinical Research Unit, Italian Institute of Telemedicine, Varese, Italy
Center for Healthful Behavior Change, Division of Health and Behavior, Department of Population Health, Langone School of Medicine, New York University, New York, New York, United States of America
Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS, San Luca Hospital, Istituto Auxologico Italiano, Milan, Italy
Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
Primary Care Clinical Sciences, University of Birmingham, Birmingham, United Kingdom
Division of Prevention and Primary Care, New York City Department of Health & Mental Hygiene, New York, New York, United States of America
Cardiovascular Research Institute Maastricht and Departments of Internal Medicine, Maastricht University, Maastricht, the Netherlands
Department of Veterans (VA) Health Services Research and Development Centre for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City
VA Medical Centre, University of Iowa, Iowa, United States of America

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